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Weekly Chest CasesArchive of Old Cases

Case No : 1049 Date 2017-12-04

  • Courtesy of Soo-Youn Ham, M.D., Ph.D. / Korea University Anam Hospital
  • Age/Sex 53 / F
  • Chief ComplaintC/C: Incidental abnormality, P/Hx: lupus nephritis, diabetes mellitus, rheumatoid arthritis
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Marginal zone B cell lymphoma (MALT lymphoma)
Radiologic Findings
Fig. 1. Chest radiography revealed well-defined 4 cm mass with lobulated contours located in left upper lobe.
Fig. 2. Non-CECT scan revealed relatively well-defined 4.4 cm mass like consolidation with air bronchograms in the left upper lobe. Small non-calcified nodule (9mm) is shown in right middle lobe. No evidence of pleural effusion, mediastinal lymphadenopathy and endobronchial lesions.
Fig. 3. PET-CT revealed mildly hypermetabolic mass (max SUV 3.0) in the left upper lobe.

A 53-year old female who has been managed with lupus nephritis and rheumatoid arthritis over 20 years. A chest radiography was taken for routine follow up. She has no remarkable respiratory symptoms such as fever or cough. Chest radiography revealed an incidental abnormality, which was further evaluated with chest CT followed by CT guided biopsy.
Brief Review
Lymphoproliferative disease (including non-Hodgkin [B cell] and other lymphomas) can be detected during methotrexate therapy which regress after methotrexate discontinuation (1, 2-6). Among 48 patients with rheumatoid arthritis receiving methotrexate who developed a lymphoproliferative disease, the primary site was the lung in four patients (4). In a separate report, 6 of 28 cases of lymphoproliferative disease involved the lung or pleura, but details were not provided (3). The reversibility of this disease without specific anti-lymphoma treatment suggests that diminished immune surveillance due to methotrexate may facilitate the development and expansion of malignant lymphoid clones. A portion of these cases (28 %) is associated with EBV infection, a finding that is also seen in patients who are immunosuppressed in the setting of organ transplantation or AIDS (4).
The causal relationship between lymphoma and methotrexate use has been difficult to prove due to the increased rate of lymphoma among patients with rheumatoid arthritis. Large database studies suggest that it is unlikely that long-term oral methotrexate therapy increases the risk of lymphoma (7). However, there are well-documented cases of regression of lymphoma when methotrexate is held.
References
1. Weinblatt ME. Methotrexate in rheumatoid arthritis: toxicity issues. Br J Rheumatol 1996; 35:403-405.
2. Kamel OW, van de Rijn M, Weiss LM, et al. Brief report: reversible lymphomas associated with Epstein-Barr virus occurring during methotrexate therapy for rheumatoid arthritis and dermatomyositis. N Engl J Med 1993; 328:1317-1321.
3. Salloum E, Cooper DL, Howe G, et al. Spontaneous regression of lymphoproliferative disorders in patients treated with methotrexate for rheumatoid arthritis and other rheumatic diseases. J Clin Oncol 1996; 14:1943-1949.
4. Hoshida Y, Xu JX, Fujita S, et al. Lymphoproliferative disorders in rheumatoid arthritis: clinicopathological analysis of 76 cases in relation to methotrexate medication. J Rheumatol 2007; 34:322-331
5. Rizzi R, Curci P, Delia M, et al. Spontaneous remission of "methotrexate-associated lymphoproliferative disorders" after discontinuation of immunosuppressive treatment for autoimmune disease. Review of the literature. Med Oncol 2009; 26:1-9.
6. Kamiya Y, Toyoshima M, Suda T. Endobronchial Involvement in Methotrexate-associated Lymphoproliferative Disease. Am J Respir Crit Care Med 2016; 193:1304-1306.
7. Balk RA. Methotrexate- induced lung injury. UpToDate. www.uptodate.com/contents/methotrexate-induced-lung-injury Jul 2016.
Keywords
Lung, Neoplasm, Malignant,

No. of Applicants : 78

▶ Correct Answer : 36/78,  46.2%
  • - Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - King Abdulaziz University Hospital , Saudi Arabia Amr M. Ajlan
  • - Seoul National University Hospital , Korea (South) JAE WON CHOI
  • - Other , Korea (South) HAYEON LEE
  • - Asan Medical Center , Korea (South) HYUN JUNG KOO
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - The Jikei university , Japan TAKU GOMI
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Ajou University Hospital , Korea (South) Taeyang Ha
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Samsung Medical Center , Korea (South) MIN YEONG KIM
  • - Dong-A University, College of Medicine , Korea (South) KI-NAM LEE
  • - 怨„紐… , Korea (South) jin young kim
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Other , Korea (South) SEONGSU KANG
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Maimonides Medical Center , United States NAOMI TWERSKY
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - , Korea (South) DAE WOONG PARK
  • - The University of Tokyo Hospital , Japan TAKU TAJIMA
  • - Escola Paulista de Medicina , Brazil RENATO MASSON DE ALMEIDA PRADO
  • - Korea university medical center, guro hospital , Korea (South) Lee kyu chong
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Kyemyung University Dongsan Hospital , Korea (South) DONG HYEON KIM
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - Samsung Medical Center , Korea (South) HYUN JUNG YOON
  • - Ajou University Hospital , Korea (South) YOO YOUNGJIN
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 15/78,  19.2%
  • - Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - , Korea (South) HANKYUL KIM
  • - McGill University Health Center , Canada Alexandre Semionov
  • - The University of Tokyo Hospital , Japan Yusuke Watanabe
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - Chonnam National University Hospital , Korea (South) JONG HYEON KIM
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - District TB centre, kasaragod,India , India rikhy krishnan
  • - Teikyo University Hospital , Japan KAORU SUMIDA
  • - Private sector , Greece VASILIOS TZILAS
  • - University of Utah , United States AKIHIKO SAKATA
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Current Editor : Sang Young Oh, M.D., Ph.D Email : sangyoung.oh@gmail.com

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